2.0 Analysis 2.1 Servo-mechanism Electrical Connector Disconnection The vessel had made a number of manoeuvres requiring the use of the main engines before the occurrence which would indicate that the servo-mechanism was functioning satisfactorily. The servo-mechanism male/female connector was found disconnected after the occurrence. As the connector is enclosed in a box which is not easily accessible, the possibility of it becoming accidentally disconnected can be ruled out. Further, because it was not provided with a locking mechanism, the connector could become disconnected as a result of vibration. As there was no evidence of unusual vibrations being experienced by the vessel, the only plausible explanation is that the connector became disconnected during normal operation of the vessel. 2.2 Handholds and Passenger Safety Because the railings along the forward observation platform's perimeter were the only handholds and because the large platform accommodates many passengers, the handholds were beyond the reach of some passengers. When the vessel moves in a seaway or during berthing/unberthing operations, passengers who are on the platform could be subjected to additional dangers associated with stumbling/falling because of a lack of sufficient handholds. 2.3 Contractual Commitment As the alterations were to increase the passenger capacity to greater than 203 and as the contract called for the carriage of some 400 passengers, the owners elected to use this vessel to fulfil their contractual commitment even though the vessel was not properly certificated. She was subsequently certificated for 371 passengers, a figure still below the number carried on this voyage. 3.0 Conclusions 3.1 Findings The GRAND FLEUVE was committed to making this voyage under a charter/rental agreement signed some three months before the occurrence. The port and starboard main engines were operating at the time of the occurrence. The starboard engine failed to respond to a command from the bridge for astern propulsion, and the vessel struck the wharf. The power supply to the starboard engine servo-mechanism had become disconnected as a result of normal vibration. The male/female electrical connector was not provided with a locking mechanism. The GRAND FLEUVE had recently undergone major structural alterations which included the addition, at the bow, of an observation platform which had railings only around its perimeter and no other handholds. Four passengers standing on the forward observation platform were slightly injured when they fell as a result of the striking. The GRAND FLEUVE was registered as a passenger vessel. The GRAND FLEUVE did not have sufficient life-saving equipment on board, did not have a valid Steamship Inspection Certificate, and did not have a valid Coasting Licence. The GRAND FLEUVE had not undergone sea trials in conjunction with the recent structural alterations. There was no system in place to accurately count the number of passengers boarding the vessel. 3.2 Causes The passenger vessel GRAND FLEUVE struck the wharf at Rivire-du-Loup as a result of the failure of the starboard main engine to respond to an order for astern propulsion. This failure was attributed to a vibration-caused electrical disconnection in the power supply to the servo-mechanism which controls the engine. 4.0 Safety Action 4.1 Action Taken In September 1992, as a result of a separate occurrence involving this vessel, a Marine Safety Advisory was forwarded to advise the Canadian Coast Guard (CCG) of the need for adequately trained and qualified crew on passenger vessels. The CCG Board of Steamship Inspection will review its decision No. 4992 regarding certification requirements for lifeboatmen on passenger vessels of less than 500 gross registered tons. Further, in February 1994, the TSB issued five marine safety recommendations with respect to charter vessels and the circumvention of safety regulations. The Board recommended that: The Department of Transport conduct a formal safety evaluation of the Canadian charter boat industry to include the adequacy of vessel inspection and crew certification requirements as well as current operational practices; The Department of Transport expedite its currently proposed amendment to the Canada Shipping Act with respect to the carriage of the fare-paying public as passengers on charter vessels; The Department of Transport encourage all charter vessel operators to equip their vessels with life-saving and emergency communication and/or signalling equipment suitable for the type of operation; The Department of Transport encourage charter boat operators to establish sailing plans and to conduct passenger safety briefings before getting under way; and The Department of Transport initiate research and development into ways of ensuring the accessibility of all emergency equipment, including in a capsizing situation. In response, Transport Canada indicated that: an all-region Working Group has been formed to address charter vessel safety issues; appropriate amendments to the Canada Shipping Act (CSA) are being considered, and drafting of the legislation will commence in a short time; a Ship Safety Bulletin (SSB) will be issued shortly to identify the obligation of charter vessel operators to operate their vessels in compliance with appropriate crewing and technical standards. Subsequently, SSB No. 4/95, Recommended Safety Communication Measures for Small Craft (including fishing and charter vessels) was issued in January 1995. The SSB advises all small craft to file sail plans to enable Rescue Coordination Centres to carry out an effective Search and Rescue operation in case of emergency. It further recommends that charter vessels conduct safety briefings on the use of life-saving equipment and on emergency procedures for passengers before sailing. The SSB also explains procedures for emergency communication using cellular telephones.